Intravenous thrombolysis or antiplatelet therapy for acute nondisabling ischemic stroke: A systematic review and network meta-analysis

Purpose: Uncertainties remain on the optimal treatment for acute minor stroke with nondisabling symptoms. The two most common therapeutic approaches are intravenous thrombolysis (IVT) and antiplatelet therapy, notably dual antiplatelet therapy (DAPT). We synthesized data from the literature to compare IVT to DAPT and identify the best treatment for this population.Method: We systematically searched Pubmed, Web of Science and the Cochrane Library for randomized trials and observational studies comparing IVT, aspirin, and/or DAPT, started within 24 h of symptom onset in patients with minor stroke (NIHSS <= 5) and nondisabling symptoms. Random-effects Bayesian network meta-analysis was conducted. The primary outcome was excellent functional outcome at 3 months (mRS 0-1). Secondary outcomes included mRS 0-2, symptomatic intracranial hemorrhage, mortality, and recurrent stroke.Findings: Four randomized trials and 2 observational studies (5897 patients for the analysis of the primary outcome) were included. Compared with IVT (alteplase), DAPT (clopidogrel + aspirin) was significantly associated with higher odds of mRS 0-1 (OR = 1.52, 95% CrI, 1.09-2.35), but aspirin alone was not (OR = 1.36, 95% CrI, 0.87-2.30). DAPT was also associated with lower odds of symptomatic intracranial hemorrhage than alteplase (OR = 0.14, 95% CrI, 0.03-0.91). There were no significant differences between treatment groups regarding the other outcomes. For each outcome, the ranking for the best treatment was DAPT, then aspirin, and then IVT.Discussion/Conclusion: This network meta-analysis suggests that DAPT may be the optimal treatment for acute nondisabling stroke, with higher odds of excellent functional outcome compared with IVT. Registration: PROSPERO ID: CRD42024522038Discussion/Conclusion: This network meta-analysis suggests that DAPT may be the optimal treatment for acute nondisabling stroke, with higher odds of excellent functional outcome compared with IVT. Registration: PROSPERO ID: CRD42024522038